Anthem BlueCross BlueShield

Anthem HealthKeepers Bronze X 5800

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $5,800.00 Family: $11,600 Per Person: $5,800
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,700.00 Family: $17,400 Per Person: $8,700

Office Visit

Primary Doctor	CoPay: $25.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our Sydney application, website, or HealthKeepers enabled device. Doctor Visits in the Home are covered.
Specialist	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered Benefit Explanation: You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our Sydney application, website, or HealthKeepers enabled device. Doctor Visits in the Home are covered.

Prescription Drug Information

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 30 day supply retail. The per-Member Cost Share for a covered prescription drug that contains insulin and is used to treat diabetes will not exceed a total of $50 per 30-day supply when obtained in-network.
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 30 day supply retail. The per-Member Cost Share for a covered prescription drug that contains insulin and is used to treat diabetes will not exceed a total of $50 per 30-day supply when obtained in-network.
Generic Drugs	CoPay: $25.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 30 day supply retail. The per-Member Cost Share for a covered prescription drug that contains insulin and is used to treat diabetes will not exceed a total of $50 per 30-day supply when obtained in-network.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 30 day supply. The per-Member Cost Share for a covered prescription drug that contains insulin and is used to treat diabetes will not exceed a total of $50 per 30-day supply when obtained in-network.

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered Benefit Explanation: In-Network Tier 2 cost shares only apply if services are billed by hospitals or facilities that are considered Tier 2 providers. Services billed by other providers are at the Tier 1 level.
Inpatient Services	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered Benefit Explanation: This benefit is for the hospital stay. In-Network Tier 2 cost shares only apply if services are billed by hospitals or facilities that are considered Tier 2 providers. Services billed by other providers are at the Tier 1 level.
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Visit(s) per Benefit Period
Benefit Explanation: Includes complete eye exam with dilation, as needed to check all aspects of vision, including the structure of the eyes. Limited to 1 visit per year.

Major Dental Care

Routine Dental Checkups for Children	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered Limit Quantity: 2 Limit Unit : Visit(s) per Year Benefit Explanation: Limited to 2 visits per year.
Routine Dental Checkups for Adults	Covered: Not Covered

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